Bone Tumours

NICE guideline [NG12] Suspected cancer: recognition and referral 1.11 Sarcomas. Last updated: Apr 2026.

Article Last Updated:04/07/2026

Bone Tumours

Bone tumours may be primary or secondary. Primary bone tumours arise from bone or cartilage, and include benign lesions as well as malignant bone sarcomas such as osteosarcoma, Ewing sarcoma and chondrosarcoma. Secondary bone tumours, or bone metastases, are more common and occur when cancer spreads to bone from another primary site.

Primary Bone Tumours

Primary Malignant Bone Tumours

There are 3 main types of malignant primary tumours, which are all sarcomas: ^[Ref]

Feature	Osteosarcoma	Ewing sarcoma	Chondrosarcoma
Cellular origin	Osteoblast-lineage (→ produces osteoid / immature bone matrix → bone-forming sarcoma)	Primitive neuroectoderm / mesenchymal cells (does NOT produce osteoid / cartilage)	Chondrocytes (→ produces cartilage matrix → cartilage-forming sarcoma)
Epidemiology	2nd most common primary bone tumour Mainly affects children, adolescents and young adults 2nd peak in incidence in 70-80 y/o More common in males	2nd most common primary malignant bone tumour Mainly affects children and adolescents (median age at diagnosis: 15 y/o) More common in males	Most common primary malignant bone tumour Mainly affects older adults (30-60 y/o)
Causes and risk factors	Previous radiation therapy Genetic syndromes (e.g. Li-Fraumeni syndrome, familial retinoblastoma)	Most cases are caused by t(11;22) Chromosomal translocation between chromosome 11 and 22 EWSR1 gene on chromosome 22 fuses to the FLI1 gene on chromosome 11	Pre-existing primary benign bone tumours (e.g. osteochondromas, enchondromas) Previous radiation therapy
Symptoms	Bone pain (esp. bone pain at night is a red flag) Loss of function of the affected limb (e.g. limping) Unexplained lump / swelling Progressive lesion / symptoms Possible pathological fractures
Diagnostic / referral pathway	Referral pathway / indications (NICE): Children and young people: Clinically suspected bone sarcoma → very urgent X-ray (within 48 hours) If X-ray suggests possible bone sarcoma → very urgent referral to specialist (within 48 hours) Adults: Consider a suspected cancer pathway referral if X-ray suggests possible bone sarcoma Standard investigations: 1st line: X-ray Confirmatory test: MRI-guided core needle biopsy
Diagnostic / referral pathway	Additional investigations: Staging with whole-skeleton (whole body CT/MRI/PET-CT or isotope bone scan) and chest imaging (CT chest)	Additional investigations: Staging with whole-skeleton imaging (whole body CT/MRI/PET-CT or isotope bone scan) Molecular genetic testing to confirm EWSR1 gene rearrangement	MDT involvement is necessary
Most commonly affected locations	Usually arise in the metaphysis of the bone Most commonly develop around the knee joint Predominantly in adults, the axial skeleton, pelvis or craniofacial bones can also be involved	Usually arise in the diaphysis of the bone Most commonly develop in long bones (e.g. femur, humerus), pelvis, vertebral column, ribs	Most commonly develop in long bones Other locations: pelvis, ribs, scapula
Radiographic features	Aggressive lesion with mixed lytic / sclerotic changes Sunburst appearance Codman triangle	“Moth-eaten” lytic lesions Laminated onion-skin periosteal reaction Possible Codman triangle	Lytic expansile lesion Rings-and-arcs calcification Popcorn-like calcification
Management	Standard curative approach: Neoadjuvant (pre-operative) chemotherapy Surgical resection Adjuvant (post-operative) chemotherapy Standard 1st line chemotherapy: MAP (methotrexate + doxorubicin + cisplatin) Inoperable disease: consider radiotherapy	Standard curative approach: Intensive chemotherapy (VDC/IE) – to be used as neoadjuvant induction and consolidation therapy Surgical resection Inoperable disease: definitive radiotherapy	Standard curative approach: Surgical resection Chondrosarcomas do NOT respond well to chemotherapy and radiotherapy Inoperable disease: consider radiotherapy

Primary Benign Bone Tumours

Disclaimer:

Primary benign bone tumours are generally less high-yield than primary malignant bone tumours for exam purposes, as they are usually less aggressive and are not typically life-threatening.

^[Ref1]^[Ref2]

Tumour type	High-yield facts	Management principle
Osteochondroma	The most common primary benign bone tumour – a cartilage-capped bony outgrowth (exostosis) from the bone surface Location: metaphysis of long bones (esp. around knee and proximal humerus) Typically presents as a painless, bony lump near the joint but can also cause mechanical symptoms (e.g. tendon irritation, bursitis) X-ray: pedunculated lesion growing away from the joint (with corticomedullary continuity)	Watchful waiting if asymptomatic Surgery is indicated if symptomatic / growing / malignancy suspected
Enchondromas	2nd-most common primary benign bone tumour – arise from ectopic remnants of the growth plate Typically asymptomatic Location: medulla of hands and feet Associated with Ollier disease and Maffucci syndrome Risk of malignant transformation into chondrosarcoma (35-50% risk) X-ray: solitary oval radiolucency with “arcs and rings” chondroid calcifications	Watchful waiting for asymptomatic lesions Simple curettage is indicated if symptomatic / risk of fracture
Osteoid osteoma	Typically affects young males (<40 y/o) Location: tibia and fibula cortex (in ~50% cases) Classically bone pain that is worse at night (and resolves with NSAIDs in <30 min as the tumour produces prostaglandins → causing the pain) X-ray: small central radiolucent nidus surrounded by dense reactive sclerosis Bone scintigraphy: double-density sign (due to the intense uptake in the central nidus and less surrounding uptake)	Can resolve spontaneously Drug of choice: NSAIDs Surgery / radiofrequency ablation only necessary if symptomatic
Osteoblastoma	Typically affects young males (20-30 y/o) Location: axial skeleton Classically bone pain that responds poorly to NSAIDs (as it does not produce prostaglandins) X-ray findings similar to those of osteoid osteoma but with a larger central radiolucent nidus and less dense surrounding sclerosis	Surgery is preferred due to aggressive potential
Giant cell tumour	Caused by RANKL overexpression → recruit osteoclasts → osteolysis Typically presents with pain, tenderness and joint effusion Associated with pathological fractures Can spread as “benign” pulmonary implants (in ~2-3% cases) Location: long bones (esp. around the knee) X-ray: lytic cystic lesion with non-sclerotic margins	Standard management: surgery Adjuvants (phenol, zinc chloride, liquid nitrogen, bisphosphonates) are necessary due to high recurrence rate Denosumab (RANKL inhibitor) is used for difficult-to-resect tumours

Secondary Bone Tumours (Bone Metastases)

Secondary bone tumours (bone metastases) are the spread of cancer from another primary site to the bone.

Bone metastases are more common than primary malignant bone tumours.

Causes

Most common cancers to metastasise to bone: prostate cancer and breast cancer (account for ~70% of cases) ^[Ref1]^[Ref2]

Other common cancers: ^[Ref1]^[Ref2]

Multiple myeloma
Thyroid cancer
Lung cancer
Bladder cancer
Renal cell carcinoma
Melanoma

Bone is the third most frequent site for cancer metastasis overall, following lung and liver. ^[Ref]

Clinical Features

Key clinical manifestations of bone metastases: ^[Ref1]^[Ref2]

Manifestation	Description / clinical features
Bone pain	Most common manifestation Poorly localised pain that is worse at night Pain may not be relieved by rest or sleep (night-time pain is a red flag) Accompanied by bony tenderness
Pathological fractures	Most commonly occurring in: Proximal parts of long bones (e.g. femur) Ribs Vertebrae (can cause spinal deformity or spinal cord compression)
Hypercalcaemia of malignancy	Typical features of hypercalcaemia: Renal stones: renal / ureteric stones, polyuria and polydipsia (from nephrogenic diabetes insipidus) Painful bones: bone / muscle / joint pain, pseudogout, muscle weakness Abdominal groans: abdominal pain, constipation, anorexia, N&V, pancreatitis Psychic moans: depression, fatigue, confusion
Metastatic spinal cord compression	Symptoms develop and progress gradually over days or longer Night-time back pain disturbing sleep – highly characteristic Severe unremitting back pain Mechanical pain (aggravated by standing, sitting or moving) Back pain aggravated by straining (for example, coughing, sneezing or bowel movements) Claudication (muscle pain or cramping in the legs when walking or exercising)
Haematological complications	Bone marrow infiltration may disrupt normal blood cell production, manifesting as: Bone marrow aplasia Anaemia Myelosuppression

Investigation and Diagnosis

Suspected bone metastases require the following work-up: ^[Ref]

FBC, U&Es, LFTs
Serum calcium and bone profile
PSA level in males
Myeloma screen
X-ray of the affected bone (image the entire bone with 2 views)
Staging with CT-TAP

A CT-TAP with no evidence of a primary malignancy may indicate a primary bone tumour → refer to a bone sarcoma centre within 72 hours ^[Ref]

Management

Optimise and treat the underlying primary cancer (if possible).

^[Ref]

Clinical manifestation	Management
Bone pain	Treatment of choice for localised moderate to severe bone pain: external beam radiotherapy If the pain is poorly localised / pain recurs in previously irradiated sites → systemic therapy Bisphosphonates Denosumab (RANKL inhibitor)
Hypercalcaemia of malignancy	Immediate management: IV fluid rehydration Further therapy: 1st line: IV bisphosphonates (e.g. zoledronic acid, pamidronate disodium) Consider denosumab if refractory to bisphosphonates or if bisphosphonates are not appropriate
Metastatic spinal cord compression	Oral dexamethasone (if suspected clinically, give the steroid immediately without waiting for MRI confirmation) Confirm the diagnosis with MRI Definitive management: surgical decompression If patient is not suitable for surgery → radiotherapy
Pathological and impending fractures	Pathological fracture → orthopaedic stabilisation (e.g. internal fixation with intramedullary nail or long-term prosthesis) followed by post-operative fractionated radiotherapy Impending fractures → prophylactic surgical stabilisation is generally preferred over waiting to fix a fracture after it occurs
Prevention of skeletal-related events	Once the diagnosis of bone metastasis is made, start one of the following: Denosumab (RANKL inhibitor) – generally preferred for its higher efficacy, better renal safety, and convenience, or Bisphosphonates Patient must be on calcium and vitamin D supplementation to avoid hypocalcaemia, and undergo a dental evaluation before initiation to reduce risk of ONJ.